Bipolar Disorder (transcript)

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Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an association of independent, locally-operated and community-based Blue Cross and Blue Shield plans, supporting solutions that make quality, affordable healthcare available to all Americans.

(MUSIC)

(DR. PETER SALGO)

Welcome to Second Opinion, where each week you get to see firsthand how some of the country’s leading healthcare professionals tackle health issues that are important to you. Each week our studio guests are put on the spot with medical cases based on real life experiences. By the end of the program, you’ll learn the outcome of this week’s case and you’ll be better able to take charge of your own healthcare – at least we hope you will. I’m your host, Dr. Peter Salgo, and today our panel includes Dr. Eric Caine from the University of Rochester Medical Center, Dr. Alice Flaherty from Harvard Medical School, author Judy Eron) and our Second Opinion primary care physician, Dr. Lou Papa from the University of Rochester Medical Center.

Our patient in today’s case is Abby. She’s 13 years old. We meet Abby and her mother in the school principal’s office, and they’ve been called there to discuss Abby’s behavior. While Abby used to be a good student, she’s been acting out recently in class, she’s been talking non-stop, and not completing her work. That is different for her. Abby’s teacher uses the words ‘restless’ and ‘disruptive’ to describe Abby. The teacher also notes that at other times Abby will not participate in class and she sits slumped in her chair refusing to talk or interact with her peers. She’s always been called hyperactive and she’s been on Ritalin for ADHD for four years. Lou, what do you think?

(DR. LOU PAPA)

I don’t usually see many 13-year olds but it’s a change in behavior which can happen pretty much at any age. A couple of things that come to mind, especially in that age group, is if there’s any drug or alcohol use that may be new. That’s a concern.

(DR. PETER SALGO)

Abby’s mother explains that Abby has struggled ever since her dad left them after several years of turmoil in the home. She promises that Abby’s behavior will change. Now the school suggested Abby get counseling but Mom says ‘Don’t worry; we’re going to work it out on our own.’ Good idea? Bad idea?

(DR. ALICE FLAHERTY)

Bad idea.

(DR. ERIC CAINE)

Common.

(DR. PETER SALGO)

Common?

(DR. LOU PAPA)

And the mother’s fears are probably boiling up here. Probably being able to handle it yourself makes it seem like it’s something you can control, that it may not be another problem – whether it’s drug or alcohol problems, mental health problems, a serious medical condition. That’s something really difficult to deal with as a parent.

(DR. ALICE FLAHERTY)

It might be worth asking her why she’s so afraid of having this intervention. She might end up telling you about another family member who had trouble and you might learn a lot about a family history of mental illness or other things.

(DR. PETER SALGO)

All this sounds great but Mom shuts down. And nothing happens until about six months later where the chart picks up again. Abby’s mom has rushed her – Abby – to the hospital because Abby took a large dose of Mom’s anti-depressants, which tells you that Mom is on anti-depressants. Abby is admitted to the psychiatry ward. Eric, what’s going to happen now?

(DR. ERIC CAINE) Well, clearly one of the questions that you want to know is what’s going on since Abby last saw the doc or saw the school people. And also it’s very clear that we don’t understand what’s going on. We’re in the dark. You have a sentinel behavior, as it were, of this overdose but you have so many possibilities about what could be contributing to this. Overdoses are common, depression is common; they don’t necessarily co-exist. Kids are upset about a lot of things – there’s a tremendous amount of information you have to get now and you have to be disciplined about this. The temptation is treat before thinking when you really want to think before treating.

(DR. PETER SALGO)

All right. Abby’s mom says that Abby has been irritable and sleepless, only sleeping two to three hours a night. These sleepless episodes are followed by days that she sleeps non-stop. She won’t get up to go to school on those days, won’t let anyone in her room, won’t talk to anyone. What do you think of this behavior?

(DR. ALICE FLAHERTY)

I’d really like to know what the cycle length is. Is this three sleepless days, three sleepy days, six months of sleepless?

(DR. PETER SALGO)

Why do you want to know that?

(DR. ALICE FLAHERTY)

One of the things I’d worry about with any cyclic behavior like that is whether it’s bipolar disorder and in children, that can have a lot of different lengths but it tends to be longer than a kid who’s just up and down because of family crises.

(DR. LOU PAPA)

I still worry about some substance abuse issues; I still worry about if there’s sexual or physical abuse at home. There are other things that I worry about that we’re not getting a handle on.

(JUDY ERON)

And that’s going on in this little girl’s life, her friendship group, and –

(DR. LOU PAPA)

Exactly.

(DR. PETER SALGO)

I can tell you that the chart takes a shortcut here. It simply says that she’s undergone a full evaluation. I’m assuming she’s had this worked up and she does now carry the diagnosis of bipolar disorder. Hearing this, her mom is devastated – I don’t necessarily say I blame her; it’s a terrible thing to have your daughter diagnosed with a psychiatric disorder. So what is bipolar disorder?

(DR. ALICE FLAHERTY)

Bipolar disorder is a state where you not only have what people traditionally think of as depressions where you have low energy, very withdrawn, but then you have states where you’re very agitated. You may not be very happy; you may look depressed to some people because you’re miserable but that alternation of energy levels is a key thing.

(DR. ERIC CAINE)

This is a situation, as best we know, that’s based on fundamental changes in brain functioning, fundamental alterations that ebb and flow. There’s a substantial amount of controversy about bipolar disorder and the diagnoses in adolescents.

(DR. PETER SALGO) She’s 13. I mean, 13 year olds are known to be moody, they’re known to be adversarial, they’re known to push back. Isn’t too early to make that kind of diagnosis?

(JUDY ERON)

Well, it is a controversy like Eric says but family history would be very important here too. Bipolar has so much genetic basis.

(DR. ALICE FLAHERTY)

It’s so easy to trivialize adolescent angst and say that ‘Oh, that’s not a disease.’ I think maybe we should start taking that more seriously because some kids go through a period where they’re really up and down and then it goes away, but to dismiss that as just a growing stage is often fatal.

(DR. PETER SALGO)

I didn’t mean dismiss it. Once you assign the diagnosis of bipolar, you pretty much carry that – you keep it like luggage that’s yours.

(DR. ERIC CAINE)

You know, if we’re really concerned that it’s bipolar, we want to pay a lot of attention because that’s potentially fatal. She’s already taught us about that. She’s taught us that she might have the potential to kill herself and one suicide attempt is certainly a risk factor for a second.

(DR. PETER SALGO)

They’ve established a diagnosis. How did they make it? In other words, what do you need to have to be diagnosed as bipolar?

(DR. ERIC CAINE)

Well, you described a lot of things already. For example, she had this sleepless period. You had a change in her mood such that she was irritable and uncooperative, disruptive – she wasn’t herself. And the thing that Alice said before is it doesn’t always have to be that they’re just elated, which a lot of people think about as manic. It can be grumpy, irritable, snappish, not yourself, combative –

(DR. ALICE FLAHERTY)

A key thing is that you have to do something that’s really disruptive, really out there; either being a danger to yourself or involved in reckless behavior or spending all your money or being violent towards other people. Somebody who just gets energetic and bad tempered doesn’t quite count. They look for things like grandiosity, thinking that you’re more important than you really are; they look for a a flood of ideas where your ideas are just zipping around, irritability as you mentioned, and talkativeness – people who just can’t stop talking. Obviously there’s nothing wrong with that in itself, but if it goes with these other things you worry.

(DR. ERIC CAINE)

So you’re looking for mood variation – up and down. You can have the mood variation on the up side go until the person is fully psychotic, fully out of touch with reality. You certainly see that much more commonly in adults but you don’t talk about bipolar unless you have the depression.

(DR. ALICE FLAHERTY)

Eric, I’m interested in that you’re putting so much emphasis on the need to see a depression because I think, in general, it’s harder to find the proof of the manic episode. We’ve already had some reports here of her being withdrawn and what’s less often reported is the manic-y stuff. So people very often present themselves as depressed and you have to really ferret out the manic stuff.

(DR. PETER SALGO)

But my question is, is she typical? In other words, a 13-year old girl, they’ve given her this diagnosis. Who gets it?

(DR. ALICE FLAHERTY)

That’s kind of a young onset. It’s not a great prognostic factor to have bipolar if she does have it that early. It’s pretty common for things like this to arise during puberty, so for this to present at 13, it fits.

(DR. ERIC CAINE)

The earlier the age of onset, long-term, the worse the prognosis. Think about late teens to early 30’s, typically but now there’s a lot of controversy and a lot of debate about earlier ages.

(DR. ALICE FLAHERTY)

Oh, I hear a lot about four year olds being diagnosed, five year olds –

(DR. PETER SALGO)

Four and five year olds?

(JUDY ERON)

Really, really young.

(DR. ALICE FLAHERTY)

And that’s where it gets really controversial.

(DR. PETER SALGO)

And that’s where you’ve got some experience with this disease, don’t you?

(DR. ALICE FLAHERTY)

Well, I have it and my manic break was pretty late life in a sense in that I was in my 30’s and it was a post-partum manic break. That’s the most common in women, post-partum, but I didn’t know that at the time.

(DR. PETER SALGO)

Is there some trigger usually to incite the onset of symptoms?

(DR. ALICE FLAHERTY)

It’s pretty easy to invent a trigger; you can always find a trigger. But there’s always something. And you know, the most common thing is sleep deprivation.

(DR. PETER SALGO)

Your husband had bipolar.

(JUDY ERON)

He had bipolar disorder and was successfully on lithium for 13 years, after having some -

(DR. PETER SALGO)

Lithium, the medication most often prescribed.

(JUDY ERON)

Lithium, the medication, and he’d had some major depression, psychotic depression, and he’d had some major mania. And then he was on lithium for 13 years and got off it abruptly. We didn’t know that in itself can trigger a manic episode.

(DR. ERIC CAINE)

One of the interesting things is that the presenting manic episode often is flagged much more quickly once it occurs because it’s so dramatic. Someone might have smoldering and recurrent depressions for years that are missed.

(DR. PETER SALGO)

How many years go by, typically, before someone is diagnosed?

(DR. ALICE FLAHERTY)

On average, it’s about seven years.

(DR. PETER SALGO)

That goes along with what you’re saying.

(DR. ERIC CAINE)

Absolutely.

(DR. PETER SALGO)

When your husband first got diagnosed, what was the triggering event? Or was there one?

(JUDY ERON)

It was before our marriage. He had been abusing marijuana, was in the Army, was abusing marijuana, got sent to a treatment center. They did not diagnose depression. But that was a long time ago; it was in the 70’s and the dual diagnosis thing. But then he had a psychotic depression where he was a street person and when he finally got picked up after two months AWOL from the Army, AWOL from his family, he was sent to a medical facility in Georgia. There thy diagnosed him and put him on lithium.

(DR. PETER SALGO)

What was it like living with somebody with bipolar disorder?

(JUDY ERON)

He was a great, wonderful person. This is a very tricky illness because people can be so well. Alice, you’re so charming and so fun to be with and so cogent in your presentation of yourself, and I’m sure, that you have to stay vigilant the rest of your life. That’s my take on it. And so Jim was a wonderful person; he was a psychologist and did very well, but people can be so well and then so not well. We got seduced by him being so well.

Well, I think one thing I want to say is that Judy knows what it’s like to live with a bipolar person and luckily, I don’t.

{laughter from group}

There are times when I am not charming, but yes, I have to constantly monitor myself and that can be a problem for patients including some of my own patients with bipolar. You can get hyper about the monitoring too, so that someone, when they get happy, they think ‘Oh my God, I’m manic.’ And they can even take more medicines, and if they’re extra scrupulous, they’ll try and keep themselves below happy, which is terrible.

(DR. PETER SALGO)

It strikes me that it would help to have someone else do the monitoring, maybe someone living with you.

(DR. ERIC CAINE)

Or a therapist. This is where therapy is really important. Coming back to Abby, I think one of the really critical issues is we don’t know what set this all in motion. Her mom and she are going to need a lot of help building their expertise so that Mom can help Abby learn about herself, which is a hard enough adolescent issue as it is anyway.

(DR. PETER SALGO)

And with that, I want to take just a little pause, sort of sum up what we’ve been discussion. We’ve covered a lot of ground. Bipolar disorder is a chemical disorder of the brain and it causes mood shifts from mania to depression. It is a life-altering illness for the person with the disorder and it’s important to remember, for the family of that person as well. We’re talking through a case – just to remind everybody – about 13-year old Abby who’s been diagnosed with bipolar disorder. On the panel with me here we have Dr. Flaherty, who has bipolar disorder, and treats people with mood disorders. Judy Eron, who’s sharing her story with us as well generously about living with someone with bipolar disorder. This brings up the question; we all have mood swings, we all go up, we all come down, we have dark days and brighter days. Do we all have some bipolar disorder in us? Can anybody develop it with the right set of triggers? Lou, you’re happy all the time –

(DR. LOU PAPA)

Yeah, life is a bed of roses. I think the difference is – that’s why we have emotions; we have emotions and they go up and down. The difference is with bipolar disorder it’s to the extreme; it’s a disruption to them, to the family around them. It’s the emotional ranges that are nonsensical. They can’t be put in the proper context.

(DR. ERIC CAINE)

This is a fatal disease with a very, very elevated suicide rate where it can be extremely dangerous. It can be dangerous in the depressions; it can sometimes be dangerous in what some people think of as the elevated state. And what’s particularly dangerous is this mixed state that you can see people in where, on the one hand, they look to an outsider like they’re feeling pretty good but you listen to them and there’s a lot of negative thought.

(DR. PETER SALGO)

Which brings us back to Abby. What are we going to do for her? Here she is, she’s in the hospital, she’s got the diagnosis. Now what do we do?

(DR. ALICE FLAHERTY)

If you can find someone who can be a therapist for her and meet with her regularly – even though I believe medications are the most important thing, the most important thing for her is convincing her that she needs to take them, and to finding something that works for her. Only a really close relationship with someone outside her family is going to do that.

(DR. ERIC CAINE)

The medicines are called ‘mood stabilizers’ so in the simplest form, you’re saying ‘We’ve got to find a way to get her mood even as much as it’s possible’. So mood stabilizers are very important.

(DR. PETER SALGO)

And the one that I was taught in medical school was lithium. Tell me about lithium.

(DR. ALICE FLAHERTY)

Lithium is a simple medication; it’s not perfect for everybody. Actually for women with mixed states, for me, it just made my cycles faster so I ended up with anti-convulsants. For the majority of people, it’s got the best track record for preventing suicide so in that respect, it’s great. But for a kid, you also have to think about side effects because if it makes her fat – if it does something she won’t tolerate – she’s just not going to take it.

(DR. ERIC CAINE)

About 25 years ago, people started looking at (carbomazapine) and other what we then used for seizures, and found that – particular for people who, for one reason or another, couldn’t take lithium – the medicines had a mood stabilizing effect. Lithium is still sort of number one in its effectiveness; these others can be extremely helpful, though, for the others who can’t take it or shouldn’t take it.

(DR. PETER SALGO)

As a non-psychiatrist, let me tell you what I’ve heard. Lithium is good. Lithium is another element, the gold standard if you will, for this. You also have to be sure this person is on board and the people around her are on board so she takes it. My suspicion is that’s where family therapy, psychotherapy, cognitive behavior therapy, all that can come in.

(DR. ERIC CAINE)

Well, let’s get fundamental. You’ve got an adolescent here, and the question for all adolescents is struggling with their own identity, struggling to figure out ‘Who am I?’ Going through all those hormonal and image changes and the acne and the growing height and the awkwardness and everything else that goes with adolescence, and you’re asking them to take ownership of management of something that may be a life-long disorder. That’s a really complicated issue.

(DR. PETER SALGO)

That’s a hit. I can tell you, they put her on lithium and they put her on an anti-depressant, an SSRI. Does that make sense?

(DR. ALICE FLAHERTY)

That worries me.

(DR. PETER SALGO) Why?

(DR. ALICE FLAHERTY)

Because of the recent studies that show SSRI’s don’t work and sometimes make it worse.

(DR. PETER SALGO)

Why?

(DR. ALICE FLAHERTY)

Because they don’t affect manic depressives the same way they affect uni-polar depressives. They can make people feel flat and irritable and sometimes provoke hypomanic and manic episodes so they can make it worse.

(DR. PETER SALGO)

How are you being treated?

(DR. ALICE FLAHERTY)

Not with anti-depressants. I’ve gone that route and I was hospitalized.

(DR. PETER SALGO)

Are you on lithium? Is that what you’re taking?

(DR. ALICE FLAHERTY)

I took lithium for a while; it certainly had an effect but one thing I have to say about my own experience with meds, I was wonderfully fortunate as a doctor that people would let me try a lot of different things. And it took me years to find a regime that was really great for me. Most people don’t have that opportunity; they see a psycho-pharmacologist, and once they get put on lithium, that’s supposed to be it for life.

(DR. ERIC CAINE)

So tailoring the medicine is going to be very, very important. And Abby’s going to have a role in this because she’s going to end up saying ‘Well, I’m willing to take certain things and not other things.’

(DR. PETER SALGO)

You’re living this from the inside out if you will; you still have mood swings?

(DR. ALICE FLAHERTY)

Yeah.

(DR. PETER SALGO)

How do you deal with that?

(DR. ALICE FLAHERTY)

It’s a little easier now after 10, 11 years of experience, but I still sometimes have to go to my psychiatrist and say ‘Am I getting manic-y or am I over-calling this?’ Luckily I have someone that I’ve worked with for a really long time. That’s so important for me to have someone who’s both my psychotherapist and my prescriber and that’s really hard to find. For me, he, much more than my family – I don’t think you should, it’s very hard for families to do that. My family still doesn’t really feel comfortable or have a sense of when I’m just being myself and annoying and being manically annoying because they’re really close together.

(DR. PETER SALGO)

Do you think it’s made you a better doctor? How has it affected your practice?

(DR. ALICE FLAHERTY)

What was amazing to me – I was very open about it, and that’s because I was manic about it and didn’t have the brains to shut up. But everyone was like ‘Oh, you were so brave.’ In fact, to my knowledge, I don’t think I ever lost a patient. In fact, I would have patients come up and say ‘I have a son that’s got this problem’ or something. What’s helped me be a better doctor is the lived experience of what it’s like to have your moods bounce around like that and to be really interested in it.

(DR. PETER SALGO)

Did you talk to people about your husband and his diagnosis?

(JUDY ERON)

I had always trusted and respected Jim. He was a brilliant, wonderful man and his change was so abrupt where he became this stranger to me and belligerent and aggressive and in my face and just full. I still was caught back; my judgment became impaired as his judgment became impaired and I didn’t want to be disloyal to him, I didn’t want to be disrespectful to him. So I didn’t take certain steps I could have. It’s a long time ago, too, before there was so much talk about bipolar.

One of the things though that I think health professionals and mental health professionals failed us was in taking us by the scruff of the neck and saying ‘It’s wonderful that you’ve met each other. It’s wonderful and great that Jim is well, and this is a cycling, chronic illness and you’re going to need to be prepared’ and what preparations a person can do to affiliate with the National Alliance on Mental Illness and Depression and Bipolar Support Alliance – and just some of the support things and resources and books. There are wonderful books and people to talk to and come out.

(DR. PETER SALGO)

Let me press you a little bit because I’m sensing something when you’re talking to me. There’s a regret that I’m hearing in your voice. There’s a sense that you could’ve done more, you could’ve helped him. Helped him because why? What happened?

(JUDY ERON)

It’s a tragedy, Peter. Jim was a psychologist, I’m a social worker. We were so ignorant and so seduced by his wellness. What I think would’ve helped Jim and me – let me go back a bit. Again, we talked so openly about his illness and it was on the table; his multiple humiliations and his life and all the things that had happened. I think it would’ve helped if he had said ‘Judy, you can’t imagine what I’m going to be like if I become manic again. I give you permission now to not be loyal to me anymore, to not be trusting of me, to not trust my judgment’ – a certain kind of permission that I didn’t grant myself once he was ill.

(DR. PETER SALGO)

And then what happened?

(JUDY ERON)

He was manic for a year and finally turned back towards me and allowed me back in and crashed really suddenly. The depression we’d been waiting for for a whole year happened and he shot himself. He had a shotgun. We lived in this remote area of Texas and he had a shotgun and he isolated himself and shot himself.

(DR. PETER SALGO)

Horrible tragedy.

(JUDY ERON)

Horrible tragedy, and of course, could I have prevented it? No, but he and I could have prepared better and had could have had more encouragement to prepare better.

(DR. ERIC CAINE)

And one of the things you’re getting is ‘Someone should’ve taught me more. Someone should have helped us both be very honest’. In the same way that we talk now about planning end of life discussions where somebody is going to help you navigate and you ask your partner ‘What do you want me to do if - ?’ In the same way, if I’m starting to lose it, what should I want from you? Or if you see your husband – if I’m the therapist and psychiatrist and you see your husband starting to lose it. While he’s well, let’s plan together about what we’re going to do because this could be an emergency. And even if he’s not, at that moment, suicidal, in three weeks it can destroy your whole life. This can be extraordinarily powerful.

(DR. PETER SALGO)

Let me pause for just a moment and sum up what we’ve been discussing. While bipolar disorder can be a challenging long-term condition, it is treatable in most cases. It can be treated with medication and psychotherapy, so making the diagnosis is important. Getting therapy, important. A very dangerous disease, left unmonitored, left untreated, this is not something you can ignore.

Let me tell you a little bit about Abby; it’s been a rocky road. She was starting to feel better on her medication and then she stopped taking her medication. She’s been hospitalized three times in the past five years. I guess this is very common, is it not? There’s hope but there’s also a rocky road in this. She’s going to have to deal with this, I suspect, for the rest of her life and so is her mom.

Well, I want to thank all of you for being here because, unfortunately, we’re out of time. You can continue this conversation on our website, www.secondopinion-tv.org, where you’ll find transcripts, videos, more about bipolar disorder and other healthcare topics. I want to thank you for watching and all of you, thank you for sharing with us. This is not easy, sharing your diagnosis, and I know it wasn’t easy sharing your story as well. So again, thank you all. I’m Dr. Peter Salgo, we’ll see you next time for another Second Opinion.

(MUSIC)

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Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association, an association of independent, locally-operated and community-based Blue Cross and Blue Shield plans, supporting solutions that make quality, affordable healthcare available to all Americans.

(ANNOUNCER)

Second Opinion is produced in association with the University of Rochester Medical Center, Rochester, New York.

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